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FUEL QUALITY COMPLAINT FORM
 Personal Information ('*'indicates a required field)
Name:
* *
*First *Last
Home Address:
City:
State:
ZIP Code:
Primary Phone: * *Example: 513-422-5555
Other Phone: Example: 513-422-5555
 
 Vehicle Information
*Make: *
*Model: * Example: Camry
Year:
 
 Station Information
Station Name: *
Station Address:
City:
State:
ZIP Code:
 
If the address is unknown please describe location.
Example: "Corner of Niles and Dixie Highway."
 Incident Report
Date Occurred Example: 01/05/2001
Type of Gas:
Was the station notified of complaint? Yes No
 
Did vehicle require repairs? Yes No
If yes, please describe.
Cost of repairs: $
Were you reimbursed for repairs? Yes No
Additional Information/Comments:

Butler County Administration Building: 130 High Street, 3rd & 4th floors, Hamilton, OH 45011 Phone: 513-887-3154 FAX: 513-887-3149
© 2017 Butler County Auditor